Provider First Line Business Practice Location Address: 
3340 HIGHWAY 19
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OWENSVILLE
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65066-2433
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
573-437-5401
    Provider Business Practice Location Address Fax Number: 
573-437-5405
    Provider Enumeration Date: 
02/08/2007